| NPI | 1700932068 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208600000X Surgery (Licence: UT 6628746-1205) |
| Additional Taxonomies | 208600000X Surgery (Licence: WA MD00039920) |
| Enumeration Date | 2007-01-26 |
| Last Update Date | 2021-09-16 |